Provider Demographics
NPI:1265665384
Name:FULL LIFE OUTREACH MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:FULL LIFE OUTREACH MEDICAL CENTER LLC
Other - Org Name:FULL LIFE OUTREACH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-791-2863
Mailing Address - Street 1:220 S CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-2619
Mailing Address - Country:US
Mailing Address - Phone:214-791-2863
Mailing Address - Fax:
Practice Address - Street 1:220 S CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-2619
Practice Address - Country:US
Practice Address - Phone:214-791-2863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8010626471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty